US Medical Insurance: How Much Choice?

[lpetrich]

David Smith on Twitter: "Buttigieg: “I trust you to figure out your own health care.”" / Twitter
I found its source:
Pete Buttigieg's 'I Trust You To Figure Out Your Health Care' Infuriates Twitter Critics | HuffPost - "But he also claimed there would be “Medicare for all who want it.”"

Paul Krugman on Twitter: "OK, true story: when I moved from Princeton, I could get health insurance either from the NYT or from CUNY (yes, I've been very privileged). NYT offered one option; CUNY 19 different plans 1/ https://t.co/PchWTWp8Af" / Twitter - followed by two more.

OK, true story: when I moved from Princeton, I could get health insurance either from the NYT or from CUNY (yes, I've been very privileged). NYT offered one option; CUNY 19 different plans. I'm fairly numerate, and even write about health care. But I couldn't figure out the difference between the CUNY plans. So I asked HR if they could summarize the differences. They said no. In the end I went with NYT (which is now essentially Medicare Advantage, since I'm 66, but looks the same to me as before). And the reason I went that way was that The Times offered me a gratifying lack of choice.

AOC responded to Paul Krugman's 2nd tweet:
Alexandria Ocasio-Cortez on Twitter: "A lot of Republicans are quite upset about critiquing the frame of “choice” within our health insurance system, with many staying that those who struggle to pick the best insurance option are simply “too dumb” to know better.
But the complexity of our system is by design. https://t.co/p1R1ejEqO2" / Twitter

Alexandria Ocasio-Cortez on Twitter: "They’re also upset that I stated 66 “choices” is too many.
It is! Healthcare is not H&M. Insurance is a complex financial product for the doctor. Costs are skyrocketing largely due to the financialization of our health.
Streamlining our system & covering more isn’t a bad thing." / Twitter

Choice is often good, like in food, clothing, cars, ... but choice in medical-insurance plans is often a choice between equally confusing alternatives. As I found out when I tried to enroll in an Obamacare plan.

Saikat Chakrabarti on Twitter: "They also conflate healthcare with health insurance. Medicare-for-all expands your healthcare choices: every doctor will be "in-network," cost-free.
What we lose is having to choose which way to pay thousands of dollars a month for the privilege to see some subset of doctors. https://t.co/OI3oOd2bYm" / Twitter

"In the network" seems like a scam. It's a way for the medical-insurance companies to claim that limited choice of doctors is somehow imposed on them.

 

[lpetrich]

AOC earlier tweeted

Alexandria Ocasio-Cortez on Twitter: "For those who can’t afford it, I feel you. I went uninsured for years bc I made “too much” for a subsidy, but couldn’t afford ~$200/mo for a $7000 deductible.
A coworker went through her entire pregnancy uninsured.That nightmare is a major reason why I fight for #MedicareForAll." / Twitter

The perils of cliff eligibility - one has a risk of falling through the cracks of such a system.

Alexandria Ocasio-Cortez on Twitter: "Members of Congress also have to buy their plans off the exchange. They are Gold plans that are partially subsidized.
That means I get to “choose” btwn 66 complex financial products.
This is absurd. No person should go without healthcare, &no one should go through this, either. https://t.co/bIeD71CD5g" / Twitter
Get 2020 health coverage. Health Insurance Marketplace | HealthCare.gov

A lot of complexity with not much gained.

Alexandria Ocasio-Cortez on Twitter: "While I am VERY thankful to finally have health insurance, it is a moral outrage that it took me *getting elected to Congress* for that to happen.
The US needs to become an advanced society. That includes establishing healthcare as a right to all people." / Twitter

Doing what most other industrialized countries have done. I recall from somewhere that when Taiwanese reformers investigated other systems, they decided that the US one was one that has just about everything wrong. They ended up deciding on a single-payer system like Canada's system and like "Medicare for All". IMO, that is good, because it does not involve creating a mega-HMO like Britain's National Health Service, and because it guarantees coverage for everyone.

Alexandria Ocasio-Cortez on Twitter: "And as someone who has now experienced many parts of the insurance spectrum (being uninsured, underinsured, and adequately insured) I don’t see how anyone can think our current healthcare system only needs a 10% improvement or a just few tweaks.
We need #MedicareForAll." / Twitter

Or else some system of multiple medical-insurance companes that cover people independent of employment. Essentially the German system, a system that goes back to Chancellor Bismarck in the late 19th cy.

AOC retweeted
Ari Rabin-Havt on Twitter: "My health should not be a commodity sold to me by corporate America.
I support a presidential candidate who will fight to make sure it isn’t." / Twitter

Also Congresspeople who will also do so. I'm annoyed by all the people who seem to think that the Presidency is the only national elected office that counts.

 

[lpetrich]

AOC retweeted
Wendell Potter on Twitter: "Lately I’ve noticed some Democratic politicians defending the current healthcare system by saying it preserves “choice” for Americans. As a former health insurance exec who helped draft this talking point, I need to come clean on its back story, and why it's wrong and a trap 1/11" / Twitter

His 11 tweets, condensed here:

Lately I’ve noticed some Democratic politicians defending the current healthcare system by saying it preserves “choice” for Americans. As a former health insurance exec who helped draft this talking point, I need to come clean on its back story, and why it's wrong and a trap.

When I worked in the insurance industry, we were instructed to talk about “choice,” based on focus groups and people like Frank Luntz (who wrote the book on how the GOP should communicate with Americans). I used it all the time as an industry flack. But there was a problem.

As a health insurance PR guy, we knew one of the huge *vulnerabilities* of the current system was LACK of choice. In the current system, you can’t pick your own doc, specialist, or hospital without huge “out of network” bills. So we set out to muddy the issue of "choice."

As industry insiders, we also knew most Americans have very little choice of their plan. Your company chooses an insurance provider and you get to pick from a few different plans offered by that one insurer, usually either a high deductible plan or a higher deductible plan.

Another problem insurers like mine had on the “choice” issue: people with employer-based plans have very little choice to keep it. You can lose it if your company changes it, or you change jobs, or turn 26 or many other ways. This is a problem for defenders of the status quo.

Knowing we were losing the "choice" argument, my pals in the insurance industry spent millions on lobbying, ads and spin doctors -- all designed to gaslight Americans into thinking that reforming the status quo would somehow give them “less choice.”

An industry front group launched a campaign to achieve this very purpose. Its name: “My Care, My Choice.” Its job: Trick Americans into thinking they currently can choose any plan they want, and that their plan allows them to see any doctor. They've spent big in Iowa.

This isn't the only time the industry made “choice” a big talking point in its scheme to fight health reform. Soon after Obamacare was passed, it created a front group called the Choice and Competition Coalition, to scare states away from creating exchanges with better plans.

The difference is, this time *Democrats* are the ones parroting the misleading “choice” talking point. And they're even using it as a weapon against each other. Back in my insurance PR days, this would have stunned me. I bet my old colleagues are thrilled, and celebrating.

The truth, of course, is you have little "choice" in healthcare now. Most can’t keep their plan as long as they want, or visit any doctor or hospital. Some reforms, like Medicare For All, *would* let you. In other words, M4A actually offers more choice than the status quo.

So if a politician tells you they oppose reforming the current healthcare system because they want to preserve "choice," either they don't know what they're talking about - or they're willfully ignoring the truth. I assure you, the insurance industry is delighted either way.

 

[lpetrich]

Here are some medical-insurance terms. Glossary | HealthCare.gov is a helpful guide.

• Premium - how much one pays each month for one's medical insurance
• Deductible - how much one has to pay before one's insurance starts to pay anything
• Copayment - how much one has to pay when one's insurance pays for something

The latter two features essentially state that insurance pays nothing up to a certain amount, and then it pays only part of what's next.

To find what "Medicare for All" advocates are advocating, I checked on:
Physicians for a National Health Program - PNHP

About Single Payer - PNHP

Single-payer national health insurance, also known as “Medicare for all,” is a system in which a single public or quasi-public agency organizes health care financing, but the delivery of care remains largely in private hands. Under a single-payer system, all residents of the U.S. would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs.

Complete with full choice of doctors.

It would be funded by additional taxes, but it would have no premiums, no deductibles, and no copays.

The site discusses two 2019 bills for implementing M4A: HR 1384 by Rep. Pramila Jayapal and S 1129 by Sen. Bernie Sanders. They are very similar, covering doctor and hospital visits, preventive and long-term care, prescription drugs, reproductive care including abortion, and dental, vision, hearing, and mental coverage.

They have different paths to full implementation, however.

PJ's House bill - Cosponsors - H.R.1384 - 116th Congress (2019-2020): Medicare for All Act of 2019 | Congress.gov | Library of Congress

Implements Medicare for All over a two-year transition period.

In the first year, current Medicare enrollees can utilize expanded benefits such as dental and vision care. After year one, the plan automatically enrolls everyone ages 0-18 and 55 and older, and also offers a Medicare Transition buy-in plan through the Federal and State exchanges during this time.

Allocates one percent of budget for the first five years to assistance for workers displaced by the elimination of private health insurance.

BS's Senate bill - S.1129 - 116th Congress (2019-2020): Medicare for All Act of 2019 | Congress.gov | Library of Congress

Provides for a four-year transition. In year one, improves Medicare by adding dental, vision, and hearing benefits and lowering out-of-pocket costs for Parts A & B; also lowers eligibility age to 55 and allows anyone to buy into the Medicare program. In year two, lowers eligibility to 45, and to 35 in year three.

Both bills specify a gradual transition to M4A.

 

[ZiprHead]

This is what Americans with pre-existing conditions still have to deal with.

 

[Loren Pechtel]

View attachment 25300

View attachment 25299

This is what Americans with pre-existing conditions still have to deal with.

Very deceptive.

Note that those numbers are the family deductible, not the individual deductible--since it's her husband that's sick the individual deductible is the relevant number. And since she's referring to her "debt", I interpret this as they don't have insurance and thus had higher bills.

Furthermore, if she's really in that much of a financial bind they would have been eligible for subsidies, those premium numbers aren't remotely right.

 

[ZiprHead]

I know a single woman, breast cancer survivor. Her premium is just over $2000 with a $6000 deductible. Silver level plan.

And subsidies are based on income. Debt has nothing to do with it.

 

[Worldtraveller]

View attachment 25300

View attachment 25299

This is what Americans with pre-existing conditions still have to deal with.

Very deceptive.

Note that those numbers are the family deductible, not the individual deductible--since it's her husband that's sick the individual deductible is the relevant number. And since she's referring to her "debt", I interpret this as they don't have insurance and thus had higher bills.

Furthermore, if she's really in that much of a financial bind they would have been eligible for subsidies, those premium numbers aren't remotely right.

The only response to this is against the forum rules.

 

[Jimmy Higgins]

Very deceptive.

Health care isn't expensive?

Note that those numbers are the family deductible, not the individual deductible--since it's her husband that's sick the individual deductible is the relevant number. And since she's referring to her "debt", I interpret this as they don't have insurance and thus had higher bills.

Does that in any way, make $1,600 a month cheaper?

Furthermore, if she's really in that much of a financial bind they would have been eligible for subsidies, those premium numbers aren't remotely right.

Yeah, nothing like subsidies. They just rain from the sky.

Anecdotally, my Dad had the option of a couple hospitals to get his cancer surgery performed. Talk about choice! Imagine if it was single payer and he could have had the option to choose from several. OMG! The horror! Okay, my Dad could have gone out of network... and paid $25,000 or so out of pocket. I guess that is "an option". I was glad, however, to have a person in family that knew the ins and outs of Medicare and insurance coverage, so we knew most of the information before hand to make an informed decision. Unfortunately, most people aren't like Loren Pechtel, with the information stuffed into the brain at birth.

I could go on about drug coverage and "choice" there. But I don't want to derail Loren's Pièce de Résistance on how deceptive it is to say insurance, medical coverage, and prescription drug costs aren't very expensive and can drag heavily on the accounts of people that busted their asses their whole life to have retirement be even more meager.

 

[SimpleDon]

David Smith on Twitter: "Buttigieg: “I trust you to figure out your own health care.”" / Twitter
I found its source:
Pete Buttigieg's 'I Trust You To Figure Out Your Health Care' Infuriates Twitter Critics | HuffPost - "But he also claimed there would be “Medicare for all who want it.”"

Paul Krugman on Twitter: "OK, true story: when I moved from Princeton, I could get health insurance either from the NYT or from CUNY (yes, I've been very privileged). NYT offered one option; CUNY 19 different plans 1/ https://t.co/PchWTWp8Af" / Twitter - followed by two more.

OK, true story: when I moved from Princeton, I could get health insurance either from the NYT or from CUNY (yes, I've been very privileged). NYT offered one option; CUNY 19 different plans. I'm fairly numerate, and even write about health care. But I couldn't figure out the difference between the CUNY plans. So I asked HR if they could summarize the differences. They said no. In the end I went with NYT (which is now essentially Medicare Advantage, since I'm 66, but looks the same to me as before). And the reason I went that way was that The Times offered me a gratifying lack of choice.

AOC responded to Paul Krugman's 2nd tweet:
Alexandria Ocasio-Cortez on Twitter: "A lot of Republicans are quite upset about critiquing the frame of “choice” within our health insurance system, with many staying that those who struggle to pick the best insurance option are simply “too dumb” to know better.
But the complexity of our system is by design. https://t.co/p1R1ejEqO2" / Twitter

Alexandria Ocasio-Cortez on Twitter: "They’re also upset that I stated 66 “choices” is too many.
It is! Healthcare is not H&M. Insurance is a complex financial product for the doctor. Costs are skyrocketing largely due to the financialization of our health.
Streamlining our system & covering more isn’t a bad thing." / Twitter

Choice is often good, like in food, clothing, cars, ... but choice in medical-insurance plans is often a choice between equally confusing alternatives. As I found out when I tried to enroll in an Obamacare plan.

Saikat Chakrabarti on Twitter: "They also conflate healthcare with health insurance. Medicare-for-all expands your healthcare choices: every doctor will be "in-network," cost-free.
What we lose is having to choose which way to pay thousands of dollars a month for the privilege to see some subset of doctors. https://t.co/OI3oOd2bYm" / Twitter

"In the network" seems like a scam. It's a way for the medical-insurance companies to claim that limited choice of doctors is somehow imposed on them.

"In the network" is a mask over one of the frailties of the for-profit health care insurance scheme. Every insurance company can't negotiate prices with every health care provider every year.

We don't need medical care insurance, we need inexpensive, readily available, and good health care. There is no good reason to give Wall Street a percentage of our annual health care costs. Other than the fact that they own one of our political parties outright and half of the other one.

The biggest threat to our capitalistic economy isn't from socialism, it is from neoliberalism.

 

[Toni]

View attachment 25300

View attachment 25299

This is what Americans with pre-existing conditions still have to deal with.

Very deceptive.

Note that those numbers are the family deductible, not the individual deductible--since it's her husband that's sick the individual deductible is the relevant number. And since she's referring to her "debt", I interpret this as they don't have insurance and thus had higher bills.

Furthermore, if she's really in that much of a financial bind they would have been eligible for subsidies, those premium numbers aren't remotely right.

I dunno. My friends practiced law in a small town until they closed the practice. Out of pocket for them was $10K EACH, not together. Their premiums were significantly higher than what that image shows--if I remember correctly >$2K/month for the two of them but by the time they could afford the insurance (purchased through a professional association), there was a history of cancer so that also drove up premiums for them--this was before ACA and their prices did not go down post ACA. For years, they were uninsured because they couldn't afford to cover their minor children and themselves AND pay for coverage for any employees required to support the practice so they just covered the kids and their employees. Eventually the kids grew up and were independent and my friends were able to pay for insurance for themselves.

 

[krypton iodine sulfur]

Coming from outside the American system(s), it's hard to understand what various health care schemes in the US are trying to accomplish. Portions of it seem like it's just leveraging health care as an employment benefit rather than an attempt to make health care more broadly accessible to people without incurring unmanageable debt burdens.

 

[Jolly_Penguin]

This isn't difficult people. Join the rest of the modern world already, and adopt universal single payer health care. Health care should be a right. Nobody should die because they can't afford good health insurance, and you should be able to see whatever doctor you need to see, regardless of if they are "in program". I go to any walk in clinic or hospital I want, and can get a referral to any specialist I want, all paid for collectively. That means peace of mind, the elimination of for-profit insurance, a healthier populace, and a lower overall cost. This is a no brainer, and once you get with in and have it for a few years it will feel as natural as public high schools and libraries, and the military existing, all funded collectively.

 

[Toni]

Coming from outside the American system(s), it's hard to understand what various health care schemes in the US are trying to accomplish. Portions of it seem like it's just leveraging health care as an employment benefit rather than an attempt to make health care more broadly accessible to people without incurring unmanageable debt burdens.

It's actually leveraging health care coverage in order to maximize profits for insurance companies.

Good employers do their best to offer their employees the best health care coverage that the company and the employees can afford. Normally, the company pays the bulk of the premiums and the employee pays a share. This allows the employer to get good health care coverage at an affordable price because they get a special rate from the insurance company.

There are lots of problems associated with this. If the company isn't large enough to get the big group discount or if it has even one or two employees who get cancer and need chemo, rates can quickly escalate to unaffordable for anybody while reducing the amount of coverage. For very small employers, it's a huge dilemma about how to best offer employees health insurance.

Tying health care coverage to employment can be a great selling point as an employer for companies. It can and does often keep people who would prefer to retire on the payrolls--and so keeps younger people out of the job.

 

[Toni]

This isn't difficult people. Join the rest of the modern world already, and adopt universal single payer health care. Health care should be a right. Nobody should die because they can't afford good health insurance, and you should be able to see whatever doctor you need to see, regardless of if they are "in program". I go to any walk in clinic or hospital I want, and can get a referral to any specialist I want, all paid for collectively. That means peace of mind, the elimination of for-profit insurance, a healthier populace, and a lower overall cost. This is a no brainer, and once you get with in and have it for a few years it will feel as natural as public high schools and libraries, and the military existing, all funded collectively.

I don't disagree--except I see Congress and I saw the kinds of restrictions they wanted to place on women's health care. And I also see that in some communities, maybe most, public libraries and public schools are really facing diminishing budgets and diminishing support.

We've got the money. I know that we do. We just are not investing it in our people via education, public services such as libraries (and often, roads, police force, home inspections, fire department--often volunteer in the US) and so on.

If Canada is able to avoid these ills, then good. I hope we get our collective heads out of our asses and move forward. As it is, I just accompanied my husband for his check up and the doctor was telling him that it was better to have certain things taken care of before he was on Medicare. Why on earth that should make any difference is beyond me. But it does indeed give me pause.

I believe that everybody should have the same level of medical coverage and that it should be excellent--although I am not opposed to co-pays for those who can afford them or do not have seriously or chronically ill or disabled or elderly members in which case those individuals/families should have zero co-pay. Medications should be easily affordable and there should be a sliding scale for lower income or high need patients. Elective cosmetic surgery shouldn't be covered but pretty much anything else should be.

 

[Loren Pechtel]

I know a single woman, breast cancer survivor. Her premium is just over $2000 with a $6000 deductible. Silver level plan.

And subsidies are based on income. Debt has nothing to do with it.

Look at the screenshots. Family plan. And if you're not getting subsidies you're making enough you can afford those premiums.

 

[Loren Pechtel]

I dunno. My friends practiced law in a small town until they closed the practice. Out of pocket for them was $10K EACH, not together. Their premiums were significantly higher than what that image shows--if I remember correctly >$2K/month for the two of them but by the time they could afford the insurance (purchased through a professional association), there was a history of cancer so that also drove up premiums for them--this was before ACA and their prices did not go down post ACA. For years, they were uninsured because they couldn't afford to cover their minor children and themselves AND pay for coverage for any employees required to support the practice so they just covered the kids and their employees. Eventually the kids grew up and were independent and my friends were able to pay for insurance for themselves.

What came before the ACA isn't evidence about what the ACA does.

 

[ZiprHead]

I know a single woman, breast cancer survivor. Her premium is just over $2000 with a $6000 deductible. Silver level plan.

And subsidies are based on income. Debt has nothing to do with it.

Look at the screenshots. Family plan. And if you're not getting subsidies you're making enough you can afford those premiums.

So your backing off on your claim about debt?

You have no idea of the situation these people are in. Obviously the father has a major illness or disease that could have caused a great deal of medical expenses so your assumptions mean jack shit.

 

[southernhybrid]

If Canada is able to avoid these ills, then good. I hope we get our collective heads out of our asses and move forward. As it is, I just accompanied my husband for his check up and the doctor was telling him that it was better to have certain things taken care of before he was on Medicare. Why on earth that should make any difference is beyond me. But it does indeed give me pause.

I am a bit curious as to what type of things your husband's doctor meant. Medicare does cover a large number of free preventative tests and procedures, like mammograms, colonoscopies, most blood tests if you have an appropriate diagnosis, screening for osteoporosis etc. etc. Or was he referring to a particular procedure or surgery that would require more out of pocket expense under Medicare coverage? Being the cynic that I sometimes am, especially when it comes to doctors and US healthcare, I also have to wonder if this doctor is thinking of how much higher his reimbursement is, if it comes from private insurance instead of Medicare, which usually pays a lower reimbursement. Of course, you know this doctor personally, so I might be way off base in thinking that, but I know that many doctors do whine about the lower reimbursement they receive from Medicare. It's a much larger problem when it comes to hospitals.

The thing that most people who aren't familiar with Medicare, don't realize is that Medicare isn't free. Part B premiums will rise to 144 plus change as of 1/2020 and that only covers 80 percent of outpatient. Part D premiums vary widely and there are always copays for drugs. Many times the copays are unaffordable. Supplements or Medications-gap policies as they are often called, can cost over 350 per month. As we age, these premiums are usually the highest. And, more than 1/3 of Medicare recipients opt for Advantage Plans, which are actually provided by private insurance companies but subsidized by the federal government.

One of my other concerns is fraud and abuse of Medicare regulations. Some years it's as much as 10 percent of the total Medicare payouts. How much will it cost to manage that? Can it be effectively managed? I'm not sure. It's very easy to cheat with Medicare, as most things aren't audited for necessity. It's easy enough for a doctor to fudge a diagnosis and order more tests and procedures than necessary. There is not rule for prior approval, which is great for the patient but can be costly. Out right fraud may be less common but it still happens at an alarming rate. Hospitals and providers are known to sometimes bill for services that were never rendered. This has been a problem for many years. Yet, I have yet to hear anyone who supports M4A, address this issue.


It's complicated and until some of these issues can be answered in a realistic way, I'm highly skeptical that M4A is a good idea.

I totally agree that we need to have some sort of UHC which is affordable for all. We already have Medicaid for the poorest people. What about those who are too young and able bodied for Medicare? There must be ways to help all without having one federally financed program. The ACA failed largely due to the obstruction from the Republicans. Premiums were reasonable in the beginning, but instead of making it better, the Repugs have done their best to destroy the ACA. Why does anyone think there will be enough support from Republicans and moderate Democrats to pass M4A, if they can't even work together to come up with some type of UHC that's not single payer? I'm also not sure that we really want the federal government responsible for our entire healthcare system. In Canada, each province reimburses for care. From what I've read, the providers receive their money quickly. This isn't always the case with the US Medicare system. It's overly bureaucratic and can take a long time to reimburse for services.

No country as large as the US has single payer. In fact, only 20 countries have single payer and most of them are small. It's unreasonable for politicians to simply promise M4A, when that actually happening is close to impossible.

 

[Tom Sawyer]

No country as large as the US has single payer. In fact, only 20 countries have single payer and most of them are small. It's unreasonable for politicians to simply promise M4A, when that actually happening is close to impossible.

Why would that be some kind of consideration? Yes, you have ten times the population of Canada, but you also have ten times the population of Canada so there's that many more people paying into the system. The concept behind it scales up easily.